Psychiatry 'bible' gets two doses of criticism

In his 1993 classic, "Listening to Prozac," Peter D. Kramer discusses how psychotropic drugs affect the art and science of psychiatric diagnosis. The successful use of lithium to treat manic depression, for example, helped substantiate the diagnosis and define the disease's boundaries.

Then Kramer, with his customary agility, complicates the picture: Because of lithium's efficacy, he writes, "American psychiatrists became such enthusiastic diagnosers of manic depression [now called bipolar disorder] that today only half of the patients who receive that diagnosis respond to lithium," severing the formerly reliable link between drug and disease.

That single example only begins to hint at the fluid nature of psychiatric diagnosis, which today seems more contested than ever. It is dependent not just on drug response, which can vary from person to person, but on the subjective observation of fluctuating symptoms that may denote different diseases or syndromes — or, some might argue, mere eccentricities of personality.

The promise of neurology — that it would someday find physiological correlates for mental disorders — has yet to be fulfilled. Without biological certainty, psychiatrists and other mental health professionals are left with theory, conjecture, experiment and the choice of disentangling or aggregating ("splitting" or "lumping") the outward manifestations of apparent illnesses.

The latest guidebook to this potholed and ill-lit territory is the 5th edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders," popularly known as DSM-5. The last major revision of the manual, DSM-IV, appeared in 1994. So the publication in May of this version of the so-called bible of psychiatry is a generational event, with cultural, scientific and practical significance for everyone from insurance companies to potential patients.

To many critics, this veritable doorstop of a book, 947 pages long, has been a massive disappointment. In recent weeks, even the National Institute of Mental Health has rejected its use as a research paradigm. The DSM-5 has taken hits for the alleged lack of transparency involved in its assembly, the profusion of new diseases it creates (including "hoarding disorder" and, for temper-tantrum-prone children, "disruptive mood dysregulation disorder") and its inability (not unlike DSMs past) to constitute anything beyond a series of guesses to be hazarded until something better comes along.

Two necessary new books sum up the complaints. The more engaging, radical and generally delectable of the two is Gary Greenberg's "The Book of Woe: The DSM and the Unmaking of Psychiatry." The author of "Manufacturing Depression" (2010), Greenberg is a practicing psychotherapist who writes with the insight of a professional and the panache of a literary journalist.

By contrast, Allen Frances' "Saving Normal: An Insider's Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life" can seem plodding and repetitive. But its importance lies in the fact that Frances himself is a former pillar of the psychiatric establishment, the chairman of the task force that developed DSM-IV, and now a staunch critic of many of his former colleagues.

Greenberg's perspective is that specific mental diseases are for the most part social constructs, devoid of scientific validity — and that to presume otherwise is farcical and misleading. In Greenberg's view, various missteps in the development of the DSM-5 are merely more nails in the coffin of psychiatric diagnosis.

In his brilliant take-down of the psychiatric profession, Greenberg begins with an inflammatory example: the 19th-century positing of a malady dubbed "drapetomania," whose main symptom was running away from slavery. A more recent and better-known case is psychiatry's struggle with homosexuality, considered a psychiatric condition until 1973. Immediately before then, Greenberg writes, the listing of homosexuality in the DSM "meant that doctors could get paid to treat it, scientists could search for its causes and cures, employers could shun its victims, and families could urge them to seek help, even as gay people conducted their intimacies in furtive encounters, lived in fear and shame, lost jobs, forwent careers, and chained themselves to marriages they didn't want."

From there, Greenberg homes in on the present-day consequences of the DSM, including what he sees as the overly widespread use of antidepressants, often with crippling side effects, and the medication of children allegedly suffering from bipolar disorder, resulting in yet more side effects.

He, too, has been implicated, he says, as "a mental health professional who has been faithfully filling out insurance forms for thirty years, jotting down those five-digit codes from the DSM that open the money taps, rendering diagnoses even though you're pretty sure you're not treating medical conditions."

Greenberg's larger critique, about the squishiness of diagnostic categories and the fallibility of diagnosis in general, is the chief strength of his book. But he also is angry about the monopoly that psychiatrists (as opposed to other mental health professionals) exert on diagnosis through the DSM, and the fact that its publication is a profit center for the American Psychiatric Association.

"The Book of Woe" offers a lucid and useful history of classification attempts in psychiatry — what is known as nosology. Greenberg argues that as psychoanalysis, which dominated American psychiatry in the mid-20th-century, came to seem more metaphysics than science, the profession shifted to the description of symptoms. That was the underlying ideology of the DSM-III, the book that "restored both internal and external confidence in psychiatry," Greenberg writes.

Yet while "descriptive psychiatry was no small achievement," the continual revision of the DSM showed that "the categories, the boundaries between them, and the criteria within them" were "not discoveries of nature at work" but rather "approximations" based on both observation and opinion.

Greenberg himself is not simply a philosopher of mental illness. He has interviewed, with surprising sympathy, many of the prime movers behind the DSM, including the psychiatrists Robert Spitzer (who helmed DSM-III); his successor, Allen Frances (DSM-IV); Michael First (DSM-IV-TR); and David Kupfer and Darrel Regier (DSM-5).

He details — possibly more than we require — DSM-5 struggles over a variety of issues: whether grief due to bereavement should be diagnosed as depression; what sort of labels should apply to oppositional, moody kids; whether to collapse autism variants (including Asperger syndrome) into a single disorder, and more. He describes with relish political infighting, including Frances' key role as a critic.

Frances' "Saving Normal" further delineates his critique. As his title indicates, he believes that psychiatric diagnosis has been running amok. He views unverifiable new diseases, paired with direct consumer advertising, as a bounty for drug manufacturers, or "Big Pharma." He worries about the dominance of biological psychiatry and the proliferation of drug side effects.

Frances begins his book with a mea culpa. Even his own, more conservative DSM-IV, he says, with its "temporarily useful diagnostic constructs," failed to predict or prevent "three new false epidemics of mental disorder in children — autism, attention deficit, and childhood bipolar disorder." It also failed, more generally, "to contain the rampant diagnostic inflation that was already expanding the boundary of psychiatry far beyond its competence."

Today, he is concerned that "loose diagnosis is causing a national drug overdose of medication" — with an astonishing 80 percent of prescriptions being written by primary-care physicians, rather than psychiatrists, who presumably would know better.

Equally troubling, Frances argues, psychiatric resources are badly misallocated, with the "worried well" receiving too much treatment, and the severely mentally ill too little. At a single party chatting with colleagues, he says, he found himself "qualified for many of the new disorders," including "binge-eating disorder" for his attacks on the buffet and "major depressive disorder" for his grief over his wife's death. (Instead of collapsing grief into depression, a controversial change under discussion, the final version of the DSM-5 includes a footnote seeking to distinguish the two.)

Unlike Greenberg, Frances doesn't want to blow up psychiatric diagnosis, but rather to restrain it — and in the process preserve both psychiatry and the realm of the normal. Yet he is humble enough to confess that "normal" can't be clearly defined, not without biological markers that don't yet exist. That, he says, "means that all of our diagnoses are now based on subjective judgments that are inherently fallible and prey to capricious change" — a conclusion that places him uncomfortably close to Greenberg on the philosophical spectrum.

Julia M. Klein is a cultural reporter and critic in Philadelphia and a contributing editor at Columbia Journalism Review.

"Diagnostic and Statistical Manual of Mental Disorders"

By the American Psychiatric Association, American Psychiatric Publishing, 947 pages, $149 paperback

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